IMPLEMENTING INTEGRATED MULTIDISCIPLINARY MODELS OF CARE. DEBRA STARR INTEGRATED SERVICE AND PLANNING MANAGER
INTEGRATED COORDINATED CARE HOW WE ARE CHANGING HOW WE WORK Aims and Objectives Strategy Past Pilots Results Overcoming barriers to implementation Current model of implementation Current Pilots Evaluation
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AIMS Stream-lined, coordinated service for those entering our system with complex and/or chronic diseases. Client-centred approach using self-management models of care. Services focusing on not just presenting issues, but risk prevention and holistic management of health issues. Coordinated Care planning and discharge.
REACTIVE
PROACTIVE
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OBJECTIVES OF CBCHS INTEGRATED COORDINATED CARE
Multidisciplinary Teams
Interdisciplinary Assessment
System Redesign
Consumers Active Partners
Processes/Evaluation/Quality
Training and Support
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STRATEGY Driver Strategic Plan Operational Plan Team Planning Identification of change champions
A PRIORITY FOR ORGANISATION 5
COMMUNICATION STRATEGY Client Information
Board Newsletter Teams
MEC Forum
Focus Group
Team Leaders
Program Managers
Client participation Meetings
Questionnaire 6
BACKGROUND PILOTS Pilot – PDSA Approach Interdisciplinary Assessment
Learning's from the design and implementation of the tool
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INTERDISCIPLINARY ASSESSMENT Patient and Carer Issues Physical
Psycho-social
Cognitive
Functional
Interdisciplinary Assessment Team Based Assessment Health Needs Identification Planning 8
Goals
Actions
PILOT 2
6 month pilot study (2012) Investigated the implementation of how an Integrated chronic disease model of care could be introduced into the Primary Health Service at CBCHS. Involved 22 staff members. Training provided on self-management of chronic disease 3 multidisciplinary pilot groups
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RESULTS Understanding and confidence Job satisfaction Identification of client priorities Collaboration, coordination a resources
Multidisciplinary Teams
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OVERCOMING BARRIERS TO IMPLEMENTATION
Discipline Specific Verses Multidisciplinary Change ‘like the way things are’ We already work in an integrated model Previous Pilots and getting staff on board Confidence Time, Wait Lists, Competing Priorities Processes/tools/TRAK
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SYSTEM RE-DESIGN CBCHS Client Flow Chronic/Complex Clients
IHT* SLOW STREAM Chronic/Complex Low Self-Mangement skills
Health Needs Assessment Care-Planning/Coordination Promote and Maintain SelfManagement Skills Referral
Health Needs Assessment Intensive Care Planning/Coordination Self-Management facilitation Referral Advocacy Case-conference
MEDIUM STREAM Chronoic/Complex Ability to Self-Managing
FAST STREAM Clients using 1 service
Health Needs Assessment Less intensive intervention Referral Self-management as need identified
Intake INI Identification of Chronic/Complex clients for IHT
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NEW PILOT INTEGRATED HEALTH TEAM (IHT)
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EVALUATION
ACIC
PACIC
Audit
Focus Group
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FOCUS GROUP RESULTS
One holistic assessment reduced duplication/ better understanding of clients needs Development of Tools: case discussion, care planning, discharge Trust in other Services/ Job satisfaction Collaborative care planning/joint consultations/case conference/home visits Primary Clinician/Learn from others/peer supervision Client outcomes Observed: less hospitalisation, increased confidence, independently attending appointments
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VIGNETTE
Before Frequent nonattender Doctor Shop Not taking Medications Lack of social support Mistrust in health system Reduced ability to manage conditions
After Attending Appointments Taking Medications Has formulated Goals Walking with an aid Wearing shoes Has council services Has trust in health system Increased Confidence Improvement in health 16 status
LEARNING'S
Model of implementation takes time Variable evidence suggests that some Health Professionals are on board and some are not. Model and process have been implemented in a pilot with positive results
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FUTURE DEVELOPMENTS
The challenge ahead to further implement an Integrated coordinated system across all sites. All Health professionals completing a interdisciplinary assessment on all clients entering our services.
Debra Starr
[email protected] 18
